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K0291
C

Lack of Documentation for Emergency Lighting Testing

Lititz, Pennsylvania Survey Completed on 07-01-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide documentation verifying that monthly and annual testing of battery-powered emergency lighting had been performed, as required by NFPA 101 standards. During a document review, it was found that there was no record of these required tests for the emergency lighting sources. This was confirmed in an interview with the DON and Director of Maintenance, who acknowledged that documentation for the testing of installed back-up emergency lighting could not be provided. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was included in the report.

Plan Of Correction

1. The facility is unable to retroactively perform this testing. 2. Monthly and annual battery-powered emergency lighting tests were completed in July. 3. The Environmental Services Director was re-educated on the requirements of K0291. Monthly battery-powered emergency lighting tests are scheduled. Annual testing will occur in July of each year. 4. The NHA or designee will complete an audit of the battery-powered emergency lighting testing monthly x 6 months. Annual testing will be confirmed in July. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.

See complete original report
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